Showing papers by "American Pharmacists Association published in 2014"

Ketamine: An Update on Its Abuse

Abstract: Ketamine is a dissociative anesthetic and substance of abuse. Numerous effects can result from the abuse of ketamine. Death from acute direct toxicity is rare. Ketamine can alter numerous functions in the brain including color perception, memory, attention, cognition, reaction time, and sense of time and can produce psychological addiction. Chronic ketamine abuse can produce toxicity to the gastrointestinal and urinary tract. Gastrointestinal changes include epigastric pain, hepatic dysfunction, and impaired gallbladder activity. The most common urological condition from ketamine is cystitis but renal failure has been reported.

Automated preparation of chemotherapy: quality improvement and economic sustainability.

Abstract: Purpose The quality and economic implications of manual versus automated preparation of antineoplastic drugs were compared. Methods This four-week study evaluated 10 routinely used antineoplastic drugs (fluorouracil, cyclophosphamide, gemcitabine, trastuzumab, bevacizumab, oxaliplatin, cisplatin, paclitaxel, irinotecan, and etoposide) prepared by manual and automated procedures. The accuracy of the dose of the active ingredient was calculated in terms of percent relative error for the difference between the nominal value indicated on the prescription and the actual value of the drug in the finished product. A comparative economic analysis of the manual and automated preparation procedures was performed by calculating the mean unit cost for each preparation at different production levels. Participating pharmacists and technicians completed a survey rating each preparation method in terms of performance, operator satisfaction, technology, and safety. Results Of the 2500 i.v. antineoplastic preparations made in the pharmacy during the four-week study period, 681 were analyzed (348 using the automated procedure and 333 manually). Of these, 17 varied by more than 5% of the prescribed dose, and 1 varied by over 10%. Accuracy, calculated in terms of average percent relative error, was the highest and lowest during manual preparation. The preparation time for individual drugs was always higher when prepared using the automated procedure. A lower mean variable unit cost was observed for preparations made using the automated procedure. Questionnaire results revealed that operators preferred the automated procedure over the manual procedure. Conclusion Both the automated and manual procedures for preparing antineoplastic preparations proved to be accurate and precise. The automated procedure resulted in substantial advantages in terms of quality maintenance standards and risk lowering.

Implementation of targeted medication adherence interventions within a community chain pharmacy practice: The Pennsylvania Project

Abstract: Objective To identify facilitators and barriers to implementing targeted medication adherence interventions in community chain pharmacies, and describe adaptations of the targeted intervention and organizational structure within each individual pharmacy practice. Design Qualitative study. Setting Central and western Pennsylvania from February to April 2012. Participants Rite Aid pharmacists staffed at the 118 Pennsylvania Project intervention sites. Main outcome measures Qualitative analysis of pharmacists’ perceptions of facilitators and barriers experienced, targeted intervention and organizational structure adaptations implemented, and training and preparation prior to implementation. Results A total of 15 key informant interviews were conducted from February to April 2012. Ten pharmacists from “early adopter” practices and five pharmacists from “traditionalist” practices were interviewed. Five themes emerged regarding the implementation of targeted interventions, including all pharmacists’ need to understand the relationship of patient care programs to their corporation's vision; providing individualized, continual support and mentoring to pharmacists; anticipating barriers before implementation of patient care programs; encouraging active patient engagement; and establishing best practices regarding implementation of patient care services. Conclusion This qualitative analysis revealed that there are a series of key steps that can be taken before the execution of targeted interventions that may promote successful implementation of medication therapy management in community chain pharmacies.

Evaluation of dabigatran for appropriateness of use and bleeding events in a community hospital setting.

Abstract: Oral anticoagulation has changed drastically in the past 4 years with the US Food and Drug Administration (FDA) approval of 3 new agents—dabigatran, rivaroxaban, and apixaban. Warfar-in has had a primary role in oral anticoagulation therapy for many decades. Although its efficacy and safety have been established, therapy with warfarin is associated with significant challenges, including the need for frequent monitoring, drug interactions, a delayed time to onset, and a narrow therapeutic index.1,2 The challenges associated with warfarin not only affect its efficacy, but they also impact patient satisfaction. These concerns have contributed to the development of novel oral anticoagulants, beginning with dabigatran etexilate. Dabigatran etexilate, a direct thrombin inhibitor, was approved by the FDA in October 2010 and is the first novel oral anticoagulant approved to reduce the risk for stroke in patients with nonvalvular atrial fibrillation (NVAF).3 Results from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) study demonstrated the superiority of dabigatran 150 mg orally twice daily compared with warfarin for the prevention of stroke and systemic embolism in patients with NVAF.4 In that study, the rate of major bleeding was similar between the agents; however, dabigatran demonstrated a lower risk for intracranial hemorrhage, but with an increased risk for major gastrointestinal (GI) bleeding, compared with warfarin.4 A recent analysis performed by the FDA confirmed these findings.5,6 In this analysis, compared with warfarin, dabigatran demonstrated lower rates of ischemic stroke, intracranial hemorrhage, and death; however, dabigatran was associated with a significant increase in major GI bleeding.5,6 In April 2014, dabigatran received new FDA indications for the treatment of patients with deep-vein thrombosis (DVT) and pulmonary embolism (PE) and for the risk reduction of recurrent DVT and PE in previously treated patients. Two studies, RE-COVER and RE-COVER II, compared dabigatran 150 mg twice daily with warfarin for the treatment of DVT and PE after 5 to 10 days of parenteral anticoagulation. Both studies demonstrated dabigatran's noninferiority to warfarin.7,8 When the RE-COVER study was initiated, dabigatran was the only agent approved by the FDA for the risk reduction of recurrent venous thromboembolism (VTE). In November 2011, rivaroxaban, a factor Xa inhibitor, was the second novel oral anticoagulant to receive FDA approval to reduce the risk for stroke in patients with NVAF.9 Results from the ROCKET AF trial demonstrated the noninferiority of rivaroxaban to warfarin for the first occurrence of stroke or systemic embolism.10 In November 2012, rivaroxaban received an additional indication for the treatment of and reduction in the risk for recurrent VTE. Two studies, EINSTEIN-DVT and EINSTEIN-PE, compared rivaroxaban (at an initial dose of 15 mg twice daily for 3 weeks, followed by 20 mg once daily) with enoxaparin 1 mg/kg twice daily for at least 5 days with warfarin and then continued with warfarin after the target international normalized ratio (INR) of 2.0 to 3.0 was reached.11,12 Both studies demonstrated the noninferiority of rivaroxaban to warfarin in time to first recurrent DVT or PE event.11,12 In December 2012, the factor Xa inhibitor apixaban was the newest novel oral anticoagulant to receive FDA approval to reduce the risk for stroke in patients with NVAF.13 The ARISTOTLE trial compared apixaban 5 mg twice daily (or 2.5 mg twice daily in select patients) with warfarin.14 Apixaban was superior to warfarin for the primary end point of reducing the risks for stroke and systemic embolism. Superiority to warfarin was primarily attributable to reductions in hemorrhagic stroke and ischemic stroke with hemorrhagic transformation compared with warfarin.14 In AVERROES, patients with NVAF who were not candidates for therapy with warfarin were randomized to treatment with apixaban 5 mg twice daily (or 2.5 mg twice daily in select patients) or to aspirin 81 mg to 324 mg once daily.15 The primary objective of the study was to determine if apixaban was superior to aspirin for preventing the outcomes of stroke or systemic embolism. This trial was stopped early on the basis of a prespecified interim analysis that showed significant reductions in stroke and systemic embolism with apixaban compared with aspirin, but apixaban was associated with a modest increase in major bleeding.15 KEY POINTS ▸ Anticoagulation has changed drastically in the past 4 years in the United States with the FDA approval of novel oral anticoagulants, starting with dabigatran in 2010, rivaroxaban in 2011, and apixaban in 2012. ▸ These new anticoagulants present a safe alternative to warfarin for the prevention of stroke and systemic embolism in the setting of nonvalvular atrial fibrillation (NVAF). ▸ However, although anticoagulation has been simplified with the novel oral drugs, many safety issues must be considered when prescribing these agents. ▸ This retrospective chart review at a community hospital analyzed the appropriateness use of dabigatran, the first novel anticoagulant to receive FDA approval for the treatment of NVAF. ▸ Of the 458 patients included in this study, 76 patients were prescribed an inappropriate, mostly too high, dose of dabigatran. ▸ Although dabigatran is only approved for the treatment of NVAF, 13 patients had valvular disease. ▸ The majority of the patients were also receiving concomitant medications that are known to have drug interactions with dabigatran. ▸ These results indicate that high-risk medications require better monitoring of prescribing habits to improve patient safety and outcomes. The current guidelines for the treatment of atrial fibrillation provide a class I recommendation for warfarin (level of evidence A) and dabigatran, rivaroxaban, and apixaban (level of evidence B) for the prevention of thromboembolism in patients with a CHA2DS2-VASc score of ≥2.16 Dabigatran provides an effective alternative therapy to warfarin. It offers a predictable pharmacokinetic profile, which eliminates the need for routine monitoring of serum drug concentrations. Approximately 80% of dabigatran is excreted renally and requires dose reductions for patients with reduced creatinine clearance.17 Although dabigatran addresses some of the challenges associated with warfarin, there are remaining issues regarding the use of dabigatran. Warfarin interacts with numerous medications, disease states, and a variety of foods containing vitamin K; however, there is a great deal of clinical experience and resources available to effectively manage many of warfarin's interactions.1 Unlike warfarin, dabigatran is not metabolized by cytochrome P450 enzymes and has fewer drug interactions. Although several drug interactions with dabigatran and P-glycoprotein inducers and inhibitors have been identified, little guidance has been provided on how to address them in practice.18 Additional concerns surrounding dabigatran include the lack of a reversal agent and the lack of availability of laboratory testing to determine its degree of anticoagulation activity. Dabigatran prolongs markers of coagulation, such as the activated partial thromboplastin time (aPTT) and ecarin clotting time, and may potentially impact INR values. The aPTT can only provide an approximation of the anticoagulation effect of dabigatran, and the INR is relatively insensitive to the degree of anticoagulation. The ecarin clotting time is a more specific parameter to determine the effect of anticoagulation19; however, most laboratories are not adequately equipped to perform the laboratory test. Without laboratory parameters to guide dosing adjustments, it is unclear how to balance the drug interactions that have been identified to potentially increase or decrease dabigatran serum concentrations. The lack of monitoring also makes it difficult to manage special populations that typically require dosage adjustments (eg, the elderly, obese patients, underweight patients, and those with renal dysfunction). Since dabigatran became the first oral anticoagulant to be introduced to the US market, and the first to be included on hospital formularies, there has been a dramatic shift in the approach to anticoagulation. Laboratory markers of anticoagulation effect are no longer reliable, drug interactions require significantly less dose adjustments, and renal function continually needs to be addressed.20 The purpose of this study was to evaluate the use of dabigatran at a community hospital between December 2010 and June 2012 and to identify prescribing areas that can be improved to ensure appropriate use and patient outcomes.

Financial implications of pharmacist-led Medicare annual wellness visits.

Abstract: Objective To determine if pharmacist-led Medicare Annual Wellness Visits (AWVs) are a feasible mechanism to financially support a pharmacist position in physicians' offices. Setting Large, teaching, ambulatory clinic in North Carolina. Practice description The Mountain Area Health Education Family Health Center is a family medicine practice that houses a large medical residency program. The Department of Pharmacotherapy comprises five pharmacists and two pharmacy residents providing direct patient care. Practice innovation In April 2012, pharmacists began conducting Medicare AWVs for patients referred by their primary care physicians within the practice. Main Outcome Measures Visit reimbursement, annual revenue, number of patients who must be seen to cover the cost of a pharmacist's salary. Results A small practice requires all eligible Medicare patients to complete an AWV to generate enough revenue to support a new pharmacist position. A medium-sized practice requires a 54% utilization rate, and a large practice requires an 18% utilization rate. Two additional AWVs per half-day of clinic are needed to support an existing pharmacotherapy clinic. A total of 1,070 AWVs per year are required to support a pharmacist's salary, regardless of practice size. Conclusions AWV reimbursement may significantly contribute to supporting the cost of a pharmacist, particularly in medium- to large-sized practices. In larger practices, enough revenue can be generated to support the cost of multiple pharmacists.

Measures to improve angiotensin receptor blocker prescribing efficiency in the UK: findings and implications

Abstract: Background: Generic losartan provides an opportunity to enhance angiotensin receptor blocker (ARB) prescribing efficiency, with all ARBs essentially being similar. Initially, there was limited activity in NHS Bury (UK). This changed in March 2011 with therapeutic switching and other measures encouraging the prescribing of losartan following generics to enhance its utilization versus patented ARBs. Aim: This study aims to assess the impact of multiple measures on losartan utilization, its price and total ARB expenditure. Methods: An interrupted time series analysis was performed. Utilization was measured as prescription items dispensed, typically 28 days. Results: No immediate change in losartan utilization was observed following generics. This changed after the multiple initiatives with losartan accounting for 65% of all single ARB items dispensed by the study end. ARB expenditure was 59% below prestudy levels by the study end, which was helped by a 92% reduction in expenditure per item for losartan. Annu...

Levamisole-Adulterated Cocaine: What about in European Countries?

Abstract: Background: A wide variety of somatic complications is reported or expected among cocaine users because of the adulterant levamisole. Most of the reports come from North America. Methods: To update the data on levamisole-adulterated cocaine in European countries, we present here a synthesis of data on samples seized by the police with the detection of levamisole, the amount of levamisole in cocaine samples, European drug information reports, and clinical cases. Results: Although there is a variation in the percentage of levamisole in cocaine samples between European countries, the trend is an increase of these percentages. As in North America, levamisole is becoming the most common cocaine adulterant. First European cases of complications secondary to the use of adulterated cocaine with levamisole were skin necrosis, vasculitis, and agranulocytosis. Levamisole postmortem data concerned two cases of complications leading to death, possibly related to levamisole or its metabolite (acute coronary syn...

Achieving Therapeutic Vancomycin Levels in Pediatric Patients

Abstract: Background: Vancomycin is widely used to treat infections caused by methicillin-resistant Staphylococcus aureus. Data for dosing and monitoring of this drug in pediatric patients are lacking, and clinicians who are treating children often follow guidelines established for adults. Objectives: To examine the total daily doses of vancomycin required to reach therapeutic trough levels (i.e., 10–20 mg/L) in infants, children, and adolescents, and to assess the number of pediatric patients in whom therapeutic trough levels are achieved with current empiric doses (40–60 mg/kg daily). Methods: This chart review evaluated patients 1 month to 18 years of age for whom vancomycin was prescribed at a single institution between November 2011 and October 2012. Patients’ demographic characteristics, vancomycin dosing parameters, and subsequent steady-state trough concentrations were analyzed. Results: Overall, the proportion of patients who reached therapeutic trough levels with current empiric doses was 39% (74 of 188). The mean total daily dose (± standard deviation) required to achieve therapeutic trough levels was 57.8 ± 11.5 mg/kg for patients 1 to 5 months of age, 68.9 ± 15.4 mg/kg for those 6 to 23 months of age, 65.8 ± 13.0 mg/kg for those 2 to 12 years of age, and 55.7 ± 11.8 mg/kg for those 13 to 18 years of age. Conclusions: Common empiric vancomycin dosing regimens (40–60 mg/kg daily) are not high enough to achieve trough levels of 10–20 mg/L in the majority of pediatric patients. Given these data, the authors suggest a starting dose of 60 mg/kg daily for patients 1 to 5 months of age and those 13 to 18 years of age and a starting dose of 70 mg/kg daily for patients 6 months to 12 years of age. RESUME Contexte : La vancomycine est couramment utilisee pour traiter les infections a Staphylococcus aureus resistant a la methicilline. Or, il n’y a pas assez de donnees sur l’adaptation posologique pour ce medicament et sur son suivi pharmacologique chez l’enfant. Les cliniciens qui traitent des enfants suivent donc souvent des lignes directrices concues pour les adultes. Objectifs : Analyser la posologie quotidienne de vancomycine necessaire a l’atteinte de concentrations minimales therapeutiques (c.-a-d. 10–20 mg/L) chez le nourrisson, l’enfant et l’adolescent, et evaluer le nombre d’enfants chez qui les concentrations minimales therapeutiques ont ete atteintes a l’aide des posologies empiriques utilisees presentement (40–60 mg/kg par jour). Methodes : L’etude consistait en l’analyse des dossiers medicaux de patients âges entre 1 mois et 18 ans qui se sont vu prescrire la vancomycine, et ce, dans un seul etablissement entre novembre 2011 et octobre 2012. Les donnees demographiques des patients, les parametres posologiques de la vancomycine et les subsequentes concentrations minimales a l’etat d’equilibre ont ete analyses. Resultats : Dans l’ensemble, la proportion de patients chez qui les concentrations minimales therapeutiques ont ete atteintes a l’aide des posologies empiriques presentement utilisees etait de 39 % (74 sur 188). La posologie quotidienne moyenne (± l’ecart-type) necessaire pour atteindre les concentrations minimales therapeutiques etait de 57,8 ± 11,5 mg/kg pour les patients âges de 1 a 5 mois, de 68,9 ± 15,4 mg/kg pour ceux âges de 6 a 23 mois, de 65,8 ± 13,0 mg/kg pour ceux âges de 2 a 12 ans et de 55,7 ± 11,8 mg/kg pour ceux âges de 13 a 18 ans. Conclusions : Les posologies empiriques courantes de 40–60 mg/kg par jour de vancomycine ne sont pas assez elevees et ne permettent pas d’atteindre des concentrations minimales de 10–20 mg/L chez la majorite des patients en pediatrie. Compte tenu de ces donnees, les auteurs suggerent une dose de depart quotidienne de 60 mg/kg pour les patients âges de 1 a 5 mois et ceux âges de 13 a 18 ans, et une dose de depart quotidienne de 70 mg/kg pour les patients âges de 6 mois a 12 ans.

Do electronic discharge summaries contain more complete medication information? A retrospective analysis of paper versus electronic discharge summaries.

Abstract: Complete, accurate and timely hospital discharge summaries are important for continuity of care. The aim of this study was to evaluate the effectiveness of an electronic discharge summary system in improving the medication information provided compared to the information in paper discharge summaries. We conducted a retrospective audit of 199 paper and 200 electronic discharge summaries from a 350-bed teaching hospital in Sydney, Australia. The completeness of medication information, and whether medication changes during the admission were explained, were assessed. Further, the likelihood of any incomplete information having an impact on continuity of care was assessed. There were 1352 and 1771 medication orders assessed in paper and electronic discharge summaries, respectively. Of these, 90.9% and 93.4% were complete in paper and electronic discharge summaries, respectively. The dose (OR 25.24, 95%CI: 3.41-186.9) and route (OR 8.65, 95%CI: 3.46-21.59) fields of medication orders, were more likely to be complete in electronic as compared with paper discharge summaries. There was no difference for drug frequency (OR 1.09, 95%CI: 0.77-1.55). There was no significant improvement in the proportion of incomplete medication orders rated as unclear and likely to impede continuity of care in paper compared with electronic discharge summaries (7.3% vs. 6.5%). Of changes to medication regimen, only medication additions were more likely to be explained in the electronic (n=253, 37.2%) compared to paper (n=104, 14.3%) discharge summaries (OR 3.14; 95%CI: 2.20-4.18). In summary, electronic discharge summaries offer some improvements over paper discharge summaries in terms of the quality of medication information documented. However, explanations of changes to medication regimens remained low, despite this being crucial information. Future efforts should focus on including the rationale for changes to medication regimens in discharge summaries.

Extended Stability of Intravenous 0.9% Sodium Chloride Solution After Prolonged Heating or Cooling

Abstract: Purpose: The primary objective of this study was to evaluate the stability and sterility of an intravenous 0.9% sodium chloride solution that had been cooled or heated for an extended period of time. Methods: Fifteen sterile 1 L bags of 0.9% sodium chloride solution were randomly selected for this experiment. Five bags were refrigerated at an average temperature of 5.2°C, 5 bags were heated at an average temperature of 39.2°C, and 5 bags were stored at an average room temperature of 21.8°C to serve as controls. All samples were protected from light and stored for a period of 199 days prior to being assayed and analyzed for microbial and fungal growth. Results: There was no clinically significant difference in the mean sodium values between the refrigerated samples, the heated samples, and the control group. There were no signs of microbial or fungal growth for the duration of the study. Conclusion: A sterile intravenous solution of 0.9% sodium chloride that was heated or cooled remained stable and showed ...

Development and implementation of a pharmacist-delivered Medicare annual wellness visit at a family practice office

Abstract: Objective To describe the development and implementation of a pharmacist-delivered Medicare Annual Wellness Visit (MWV) Setting Physician-owned, private family practice office Practice innovation Pharmacist-delivered MWV Main outcome measures Patient visits and practice income Results Because of time constraints in the practice, physicians, nurse practitioners, and a physician assistant had been unable to offer MWVs, a new service available to Medicare beneficiaries under the Affordable Care Act A pharmacist who was previously providing patient care services 1 day/week at a fixed hourly rate was able to add an additional 1 day/week for provision of MWVs These visits involve updating medical and medication histories; measuring weight, mass, and blood pressure; assessing cognitive and physical function; and screening the patient and recommending preventive services From September 2012 to February 2013, 174 patients participated in the pharmacist-delivered MWV Pharmacist visits were billed using codes G0438 and G0439, and the practice realized a positive net income for the MWVs Conclusion Pharmacist-delivered MWVs are financially viable and allow for greater pharmacist participation on the primary care team

Evidence-based training and mentorship combined with enhanced outcomes surveillance to address the leading causes of neonatal mortality at the district hospital level in Ghana.

Abstract: Objective To evaluate the impact of a district hospital intervention focused on enhancing healthcare provider capacity to address leading causes of neonatal death: birth asphyxia, infection and prematurity. Methods The neonatal quality improvement initiative was launched at two intervention referral district hospitals in Ghana. Local Health and Demographic Surveillance Systems were enlisted to enhance recording of neonatal and infant deaths in the community and at the facility. After baseline site assessments, a team of local paediatric experts conducted three clinical trainings on-site at each intervention hospital. Assessments were conducted to evaluate participant knowledge before and after participation in training modules. Monthly mentorship visits provided additional training to support the adoption of essential early neonatal care practices. Results In the first year of implementation, the initiative provided focused clinical training to 278 participants. A comparison of pre- and post-training test results demonstrates significant improvement in provider knowledge (73% vs. 89% correct, P < 0.001), with even greater improvement among trainees receiving recurrent refresher training (86% vs. 94% correct, P < 0.001). Participant feedback following training revealed enthusiasm about the programme and improved confidence. Conclusions Locally led initiatives that invest directly in healthcare provider education and health systems strengthening represent a promising avenue for reducing neonatal morbidity and mortality. The NQI initiative demonstrates the positive impact of a district hospital intervention that combines on-site training, mentorship and enhanced demographic surveillance. Objectif Evaluer l'impact d'une intervention au niveau de l'hopital de district portant sur le renforcement de la capacite des prestataires de soins de sante, pour faire face aux principales causes des deces neonataux: asphyxie a la naissance, infection et prematurite. Methodes L'initiative d'Amelioration de la Qualite Neonatale(AQN) a ete lancee dans deux hopitaux d'orientation de district recevant l'intervention au Ghana. Les Systemes de Surveillance Demographiques et de Sante locaux ont ete mobilises pour ameliorer l'enregistrement des deces neonataux et infantiles dans la communaute et dans les etablissements. Apres les evaluations des donnees de reference dans les sites, une equipe d'experts pediatriques locaux a effectue trois stages cliniques sur place dans chaque hopital d'intervention. Les evaluations ont ete realisees afin d’evaluer les connaissances des participants avant et apres la participation a des modules de formation. Des visites mensuelles de mentorat ont offert une formation supplementaire pour soutenir l'adoption de pratiques de soins neonataux precoces essentiels. Resultats Dans la premiere annee d'implementation, l'initiative a permis une formation clinique focalisee a 278 participants. Une comparaison des resultats de formation pre- et post- tests a demontre une amelioration significative des connaissances des prestataires (73% versus 89% de reponses correctes, p < 0.001), avec meme une plus grande amelioration chez les stagiaires recevant une formation de perfectionnement periodique (86% versus 94% de reponses correctes, p < 0.001). Les perceptions des participants apres la formation ont revele un enthousiasme au sujet du programme et une confiance en soi amelioree. Conclusions Les initiatives menees localement qui investissent directement dans l’education des prestataires de soins de sante et dans le renforcement des systemes de sante, representent une voie prometteuse pour reduire la morbidite et la mortalite neonatale. L'initiative de l’AQN demontre l'impact positif d'une intervention au niveau de l'hopital de district qui combine une formation sur place, le mentorat et le renforcement de la surveillance demographique. Objetivo Evaluar el impacto de una intervencion a nivel de hospitales distritales, disenada para mejorar la capacidad del personal sanitario de abordar las principales causas de muerte neonatal: asfixia al nacer, infeccion y prematuridad. Metodos La iniciativa de Mejora de la Calidad Neonatal (MCN) se lanzo en dos hospitales distritales de referencia en Ghana. Se utilizaron los sistemas de vigilancia sanitaria y demografica para mejorar los registros de muertes neonatales e infantiles en la comunidad y en el centro hospitalario. Despues de una evaluacion de base, un equipo de expertos en pediatria realizo tres entrenamientos in-situ en cada uno de los hospitales que participaron en la intervencion. Se realizaron evaluaciones para determinar el conocimiento de los participantes antes y despues de los modulos de entrenamiento. Se realizaron visitas mensuales de tutoria con el fin de proveer entrenamiento adicional y apoyo en la adopcion de practicas esenciales en cuidados neonatales. Resultados Durante el primer ano de implementacion, la iniciativa ofrecio entrenamiento clinico dirigido a 278 participantes. La comparacion de los resultados de las pruebas pre- y post-entrenamiento demuestran una mejoria significativa en los conocimientos de los proveedores (73% vs. 89% respuestas correctas, p < 0.001), con una mejoria aun mayor entre los participantes que recibian sesiones de refuerzo recurrentes (86% vs. 94% respuestas correctas, p < 0.001). La retroalimentacion de los participantes despues del entrenamiento revelo entusiasmo por el programa y una mejora en su nivel de autoconfianza. Conclusiones Las iniciativas locales que invierten directamente en la educacion de los proveedores sanitarios y fortalecen los sistemas de salud representan un camino prometedor para reducir la mortalidad y la morbilidad en neonatos. La iniciativa MCN demuestra el impacto positivo de una intervencion a nivel de hospitales distritales que combina entrenamiento in-situ, la tutoria y mejoras en la vigilancia demografica.

Physician assessments of the value of therapeutic information delivered via e-mail.

Abstract: Problem addressed Although e-learning programs are popular and access to electronic knowledge resources has improved, raising awareness about updated therapeutic recommendations in practice continues to be a challenge. Objective of program To raise awareness about and document the use of therapeutic recommendations. Program description In 2010, family physicians evaluated e-Therapeutics (e-T) Highlights with a Web-based tool called the Information Assessment Method (IAM). The e-T Highlights consisted of information found in the primary care reference e-Therapeutics+. Each week, family physicians received an e-mail containing a link to 1 Highlight from a different chapter of e-Therapeutics+. Family physicians received continuing medical education credits for each Highlight they rated with the IAM. Of the 5346 participants, 85% of them were full-time or part-time practitioners. A total of 31 429 Highlights ratings were received in 2010 (median of 2 ratings per participant, range 1 to 49). Among participants who rated more than 2 Highlights, the median number of ratings was 7 (mean 11.9). The relevance of the information from individual Highlights varied widely; however, for 90% of the rated Highlights participants indicated total or partial relevance of the information for at least 1 patient. For 41% of rated Highlights, participants expected patient health benefits to result from implementing the recommendation, such as avoiding an unnecessary or inappropriate treatment, or a preventive intervention. Conclusion This continuing medical education program stimulated family physicians to rate therapeutic recommendations that were delivered weekly via e-mail. The process of rating e-T Highlights with the IAM raised awareness about treatment recommendations and documented self-reported use of this information in practice.

Metronidazole intravenous formulation use in in-patients in Kapkatet District Hospital, Kenya: a best practice implementation project

Abstract: Background Inappropriate use of intravenous antibiotic in hospitals impacts on therapeutic efficacy, bacterial resistance, cost and iatrogenic infections. The potential harm from misuse calls for an intervention to improve the use of intravenous antibiotics in hospitals. Intravenous to oral Switch therapy is one way of minimizing overprescribing of antibiotics injections. Aims/objectives Implementation of evidence based practice with regard to administration of metronidazole intravenous formulation in an in-patient setup. Methods The project was conducted over a period of six months. Pre and post implementation audit were used to assess the documentation of Metronidazole injection use in 65 patients medical records and the compliance rate compared. The audit utilized four evidence based criteria recommended by the Joanna Briggs Institute. Results Post Implementation audit of metronidazole intravenous to oral conversion evidence-based criteria showed an increase of more than 40% compliance in all the four criteria utilized. Discussion and conclusion The increase in medical record documentation indicated the contribution of audit, feedback and re-audit cycles to bring about change in clinical practice. This project has demonstrated that metronidazole intravenous formulation switch to oral therapy can be implemented, which can result in a reduction in cost, patient discomfort and iatrogenic infections. For long term sustainability of the outcome, guidelines and pharmacist leadership is essential, as well as follow up assessment of progress to determine the effectiveness of switch therapy in reduction of cost.

QT interval prolongation in users of selective serotonin reuptake inhibitors in an elderly surgical population: a cross-sectional study

Abstract: Objective To investigate the association between the use of a selective serotonin reuptake inhibitor (SSRI) and the occurrence of QT interval prolongation in an elderly surgical population. Method A cross-sectional study was conducted among patients (> 60 years) scheduled for outpatient preanesthesia evaluation in the period 2007 until 2012. The index group included elderly users of an SSRI. The reference group of nonusers of antidepressants was matched to the index group on sex and year of scheduled surgery (ratio, 1:1). The primary outcome was the occurrence of QT interval prolongation shown on electrocardiogram. The QT interval was corrected for heart rate (QTc interval). The secondary outcome was the duration of the QTc interval. The outcomes were adjusted for confounding by using regression techniques. Results The index and reference groups included 397 users of an SSRI and 397 nonusers, respectively. QTc interval prolongation occurred in 25 (6%) and 19 (5%) index and reference patients, respectively. After adjustment for confounding, users of an SSRI did not have a higher risk for QTc interval prolongation compared to nonusers: OR = 1.1 (95% CI, 0.5 to 2.0). The adjusted mean QTc interval length in users of an SSRI and nonusers was comparable (difference of 1.5 milliseconds [95% CI, -1.8 to 4.8]). Use of the most frequently used SSRIs citalopram and paroxetine was not associated with a higher risk of QTc interval prolongation nor with lengthening of the QTc interval duration. Conclusions The use of an SSRI by elderly surgical patients was not associated with the occurrence of QT interval prolongation.

"Better-than-best" evidence? Using family physicians' feedback for 2-way knowledge translation.

Abstract: Family physicians have access to numerous evidence-based electronic knowledge resources (EKRs) for retrieving treatment recommendations when needed. In addition, resources received via e-mail, such as e-Therapeutics Highlights, help FPs stay up to date. The Highlights are selected from the content

Accuracy of general practitioner medication histories for patients presenting to the emergency department.

Abstract: Background: Clinical handover and obtaining best possible medication histories (BPMH) at transition points in care are key patient safety priorities This study aimed to determine the accuracy of medication histories documented on general practitioner (GP) referral letters for patients referred to emergency departments Methods: This was a multicentre prospective observational study in eight emergency departments Patients taking >=1 regular medication, referred to the emergency department with a GP letter and seen by a pharmacist were included GP medication regimens were compared with BPMH documented by the emergency department pharmacist Results: Of the GP letters (total 414), 361 (87%) had one or more discrepancies in the patients' regular medications and 62% had one or more regular medication discrepancies of moderate-high significance Omission of medication was more prevalent in handwritten letters (P <0001), whereas inclusion of medications not taken was more prevalent in electronically generated letters (P <0001) Discussion: GP referral letters should not be used in isolation to determine the medication regimen taken before an emergency department presentation Interventions are indicated to improve awareness and accuracy of medication documentation

The association of type 2 diabetes with obesity and other factors: in multinational community

Abstract: Objective: Quantifying the influence of Obesity and other contributing factors on inducing Type 2 Diabetes is important to allow for rational planning and allocation of resources. Therefore, the major aim of this study was to estimate theinfluence of obesity on inducing Type 2 Diabetes and explore the relationship between Type 2 Diabetes and different contributing factors such as age, gender, race, type of food taken and family history in a many healthy and non-healthy human multinational volunteers in the United Arab Emirates. Methods: A stratified cross-sectional analysis observational study was conducted on 800 healthy males and non-pregnant female volunteers aged between 18 and 45 years old. A Structured Investigational Assessment (SIA) as a principle of analysis was used to find out the contributing factors and correlations between obesity and Type 2 Diabetes. SIA was well designed and highly structured to allow the same types of information to be collected from a large number of people in the same way and for data to be analyzed quantitatively and systematically. Information obtained from volunteers contained age, race, gender, weight, height, quality of food taken, smoking status, medical conditions, emotional, material and physical activity status. Pearson’s chi square test was used to study the significance of different contributing factors and obesity on inducing Type 2 Diabetes. Results: Results indicated a significant difference that was found between the presences of Type 2 Diabetes in obese volunteers compared to non-obese volunteers regardless, age, race, and gender. However, analysis showed that gender, age, race, family history with Type 2 Diabetes and quality of food taken as one of the contributed factors that can induce Type 2 Diabetes, even in the non-obese adults . Conclusion: Our findings revealed that female, Middle Eastern and obese people who consume non-healthy food are at higher risk for developing Type 2 Diabetes. This can be attributed to the lack of awareness and public health education. Therefore,the prevalence of Type 2 Diabetes is high among the United Arab Emirates population and represents a major clinical and public health problem. A national prevention program to prevent diabetes and address the modifiable risk factors at the community level, targeting high-risk groups, should be implemented.

Identifying Barriers to Medication Discharge Counselling by Pharmacists

Abstract: Background: Medication errors may occur more frequently at discharge, making discharge counselling a vital facet of medication reconciliation Discharge counselling is a recognized patient safety initiative for which pharmacists have appropriate expertise, but data are lacking about the barriers to provision of this service to adult inpatients by pharmacists Objectives: To determine the proportion of eligible patients who received discharge counselling, to quantify perceived barriers preventing pharmacists from performing discharge counselling, and to determine the relative frequency of barriers and associated time expenditures Methods: In this prospective study, 8 pharmacists working in general medicine, medical oncology, or nephrology wards of an acute care hospital completed a survey for each of the first 50 patients eligible for discharge counselling on their respective wards from June 2010 to February 2011 Patients discharged to another facility (rehabilitation, palliative care, or long-term care), those with hospital stay less than 48 h before discharge, and those whose medications were unchanged from hospital admission were ineligible Results: Discharge counselling was performed for 116 (29%) of the 403 eligible patients and involved a median preparation time of 25 min and median counselling time of 15 min per patient At least one documented barrier to discharge counselling existed for 295 (73%) of the patients Several barriers to discharge counselling occurred significantly more frequently on the general medicine and oncology wards than on the nephrology ward (p < 005) The most common barrier was failure to notify the pharmacist about impending patient discharge (130/313 [41%]) Time constraints existed for 130 (32%) of the patients, the most common related to clarification of prescriptions (96 [24%]), creation of a medication list (69 [17%]), and faxing of prescriptions (64 [16%]) Conclusion: This study generated objective data about the barriers to and time constraints associated with medication discharge counselling by pharmacists These findings should raise awareness of the challenges faced by pharmacists in busy hospital positions and may support avenues of change for their hospital discharge counselling programs RESUME Contexte : Les erreurs de medication peuvent etre plus frequentes lors du conge, ce qui fait de l’offre de conseils au moment du conge un element essentiel du bilan comparatif des medicaments L’offre de conseils au moment du conge est un service dont la valeur quant a la securite des patients est reconnue et pour lequel les pharmaciens possedent l’expertise necessaire Toutefois il y a trop peu de donnees sur les elements qui font obstacle a l’offre de ce service aux patients hospitalises par les pharmaciens Objectifs : Definir quelle est la proportion de patients admissibles ayant obtenu des conseils au moment du conge, quantifier les elements percus comme des obstacles qui empechent les pharmaciens d’offrir ce service et determiner la frequence relative des obstacles ainsi que les contraintes de temps qui y sont associees Methodes : Dans cette etude prospective, huit pharmaciens travaillant aux services de medecine generale, d’oncologie medicale ou de nephrologie dans un hopital de soins de courte duree ont rempli un questionnaire pour chacun des 50 premiers patients admissibles a une offre de conseils au moment ou ceux-ci prenaient conge de leurs services respectifs entre juin 2010 et fevrier 2011 Les patients transferes dans un autre etablissement (readaptation, soins palliatifs ou soins de longue duree), ceux dont le sejour a l’hopital etait de moins de 48 h avant le conge et ceux dont la medication est demeuree inchangee pendant leur sejour a l’hopital n’etaient pas admissibles Resultats : Un service de conseils au moment du conge a ete fourni a 116 (29 %) des 403 patients admissibles Il necessitait en moyenne un temps de preparation de 25 minutes et un temps d’offre de conseils de 15 minutes par patient Au moins un obstacle a l’offre de conseils au moment du conge a ete releve pour 295 (73 %) patients De multiples obstacles a l’offre de conseils etaient beaucoup plus frequents aux services de medecine generale et d’oncologie qu’a celui de nephrologie (p < 0,05) Le plus frequent etait que l’on negligeait d’informer le pharmacien du conge imminent du patient (130/313 [41 %]) Des contraintes de temps ont ete relevees pour 130 (32 %) patients, les raisons les plus courantes etant reliees a la clarification des ordonnances (96 [24 %]), a la creation d’une liste de medicaments (69 [17 %]) et a la telecopie d’ordonnances (64 [16 %]) Conclusion : Cette etude a produit des donnees objectives sur les elements qui font obstacle a la prestation par les pharmaciens de conseils en matiere de medicament au moment du conge et sur les restrictions de temps qui y sont associees Ces resultats devraient mieux faire connaitre les problemes auxquels font face les pharmaciens hospitaliers affaires et ils peuvent fournir des pistes de changement a leurs programmes de prestation de conseils au moment du conge

Patient aberrant drug taking behaviors in a large family medicine residency program: A retrospective chart review of screening practices, incidence, and predictors

Abstract: Introduction: Potentially aberrant drug-taking behaviors (pADTB) are described as any departure from strict adherence to prescribed use of medications for their intended indication. There are several validated instruments, processes, and databases available to assist the clinician in screening and stratifying risk for patients in which controlled substances are being prescribed or considered. Actual utilization of these tools in nonspecialist healthcare settings is largely unknown. The primary objective of this retrospective chart review was to describe utilization patterns of these common tools within a 56 physician family medicine training program. Secondary objectives included identification of site-specific predictors of pADTB and correlation of prescribing patterns with documented aberrant behaviors. Methods: A total of 202 chronic pain patients were identified for inclusion based on prior 12-month prescription and refill records within the electronic health record (EHR) from March 2008 through March 2009. Each patient included had at least one opioid for 30 days within the study period and had chronic pain symptoms for at least 90 days. Each chart was reviewed for predefined pADTB, controlled substance refill request, prescription drug monitoring profile, and post hoc investigator completion of the Opioid Risk Tool Clinician Form. Descriptive statistics and regression analysis was used to report results. Results: Clinician documentation of risk-screening tool use of any type was limited to one patient of the 202 records reviewed. Within this sample, 203 unique pADTB were documented in the EHR records of 89 (44.1 percent) patients. Patients prescribed morphine or tramadol appeared to exhibit less use of multiple prescribers and multiple pharmacies while an association between this behavior and two or more concurrent opioid prescriptions became apparent. Those taking fentanyl or morphine exhibited unsanctioned dose escalations more frequently. Conclusions: These results suggest that routine evaluation of risk for abuse or misuse of opioid analgesics occurs infrequently in a large family medicine training program. pADTB exhibited by patients using opioids for chronic pain syndromes in this sample were consistent with those reported in other similar settings. Policies and procedures in primary care settings for improved risk evaluation and ongoing monitoring of chronic opioid therapy is needed.

The effects of dentin bonding agent formulas on their polymerization quality, and together with tooth tissues on their microleakage and shear bond strength: an explorative 3-step experiment

Abstract: Purpose Bonding agents (BA) are the crucial weak link of composite restorations. Since the commercial materials' compositions are not disclosed, studies to formulize the optimum ratios of different components are of value. The aim of this study was to find a proper formula of BAs. Materials and methods This explorative experimental in vitro study was composed of 4 different sets of extensive experiments. A commercial BA and 7 experimental formulas were compared in terms of degree of conversion (5 experimental formulas), shear bond strength, mode of failure, and microleakage (3 experimental formulas). Statistical analyses were performed (α=.05). The DC of selected formula was tested one year later. Results The two-way ANOVA indicated a significant difference between the shear bond strength (SBS) of two tissues (dentin vs. enamel, P=.0001) in a way that dentinal bonds were weaker. However, there was no difference between the four materials (P=.283). The adhesive mode of failure was predominant in all groups. No differences between the microleakage of the four materials at occlusal (P=.788) or gingival (P=.508) sites were detected (Kruskal-Wallis). The Mann-Whitney U test showed a significant difference between the microleakage of all materials (3 experimental formulas and a commercial material) together at the occlusal site versus the gingival site (P=.041). Conclusion A formula with 62% bisphenol A-glycidyl methacrylate (Bis-GMA), 37% hydroxy ethyl methacrylate (HEMA), 0.3% camphorquinone (CQ), and 0.7% dimethyl-para-toluidine (DMPT) seems a proper formula for mass production. The microleakage and SBS might be respectively higher and lower on dentin compared to enamel.

Dentition abnormalities in a Timothy syndrome patient with a novel genetic mutation: a case report.

Abstract: The purpose of this paper was to present the case of a two-year-old male diagnosed with Timothy syndrome who presented with generalized enamel defects in the primary dentition. Timothy syndrome is an autosomal dominant condition characterized by a de novo missense mutation in the Cav1.2 L-type calcium channel CACNA1C. Timothy syndrome patients present with multiple clinical manifestations, including: cardiac arrhythmias; syndactyly; immune deficiency; intermittent hypoglycemia; and neurologic issues, including seizures, mental retardation, hypotonia, and autism. Craniofacial abnormalities reported include: low-set ears; flat nasal bridge; small upper jaw; thin upper lip; round face; and baldness at birth. Abnormalities in the dentition have been reported, including small, misplaced teeth with poor enamel and severe caries. At present, there is no thorough description of the dental abnormalities seen in a patient with Timothy syndrome.

Impact of a community-based diabetes self-management program on key metabolic parameters

Abstract: *Objective: Characterize the impact of a pharmacist-led diabetes self-management program on three key metabolic parameters: glycosylated hemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), and mean arterial blood pressure (MAP) among employee health program participants Methods: A self-insured company in the Kansas City metropolitan area began offering a pharmacist-led diabetes self-management program to eligible company employees and their dependents in 2008 A retrospective pre-post analysis was conducted to determine if the program affected key metabolic parameters in participants by determining mean change after one year of participation Results: Among 183 program participants, 65 participants met inclusion criteria All three key metabolic parameters were significantly reduced from baseline to one year of program participation: HbA1c decreased from 81% to 73% (p=0007); LDL-C decreased from 1083 mg/dL to 964 mg/dL (p=0009); and MAP decreased from 961 to 923 mm Hg (p=0005) Conclusions: The pharmacist-led diabetes selfmanagement program demonstrated significant reductions in HbA1c, LDL-C, and MAP from baseline to one year of program participation Improvements were statistically significant and clinically relevant for each parameter Previous studies indicate these reductions may cause reduced overall healthcare costs

[Role of pharmacists during serious natural disasters: report from Ishinomaki, the disaster-struck city].

Abstract: On August 31, 2011, five months after the Great East Japan Earthquake, Miyagi prefecture reported 9357 dead and 2288 missing citizens, whereas Ishinomaki reported 4753 dead and 1302 missing citizens. A total of 12 pharmacists in Miyagi prefecture had lost their lives. Many medical institutions at the time were rendered out of service due to damage. Ishinomaki Red Cross had to serve as headquarters of disaster medicine management for the area. The government of Miyagi and Miyagi Pharmacist Association signed a contract regarding the provision of medical and/or other related tasks. Nevertheless, the contract was not fully applied given the impact of the tsunami, which caused chaos in telecommunication, traffic, and even the functions of the government. Given the nature of the disaster, medical teams equipped only with emergency equipment could not offer appropriate response to the needs of patients with chronicle diseases. "Personal medicine logbook" and pharmacists were keys to relief works during the disaster. Pharmacists played a critical role not only for self-medication by distributing over the counter (OTC) drugs, but also in hygiene management of the shelter. Apart from the establishment of an adoptive management system for large-scale natural disasters, a coordinated system for disaster medical assistance team (DMAT), Japanese Red Cross (JRC), Self-Defense Force (SDF), and other relief work organizations was imperative.

Blood pressure targets in the very old Development of a tool in a geriatric day hospital

Abstract: Problem addressed Canadian hypertension guidelines do not address blood pressure (BP) targets in the very old (older than 85 years of age), making BP management in this group difficult. Objective of program To develop a BP target tool and implementation process in order to facilitate management of BP in the very old at the Bruyere Continuing Care Geriatric Day Hospital in Ottawa, Ont. Program description A BP target tool and implementation process were developed to target, monitor, and communicate BP goals within the care team, to the patient and family, and to other prescribers. An audit was conducted of the first 10 weeks of the tool’s implementation and illustrated good use with areas for improvement noted. Conclusion The development and use of a BP target tool increased prescriber consistency and confidence in managing BP in the very old. The tool filled a gap in the absence of guidelines specific to BP management in the very old. The BP target tool has implications for practice, as well as for the training of health care professionals involved in treating and monitoring BP in very old patients.

Etanercept induces remission of polyarteritis nodosa: a case report

Abstract: Polyarteritis nodosa (PAN) is a systemic autoimmune vasculitis characterized by necrotizing inflammatory lesions of the medium-sized and small muscular arteries, preferentially at vessel bifurcations, resulting in microaneurysms formation, aneurysmal ruptures with hemorrhage, thrombosis and consequently, organs ischemia or infarction. It usually appears in middle and older age, without gender predilection (Jennette et al., 1994). PAN shows a wide variety of symptoms, including general symptoms, neurological, skin, renal, and gastrointestinal involvement. In particular, skin lesions, characterized by multiple firm waxy papules, subcutaneous nodules, livedo reticularis, ulcers and gangrene, are observed in 25–60% of patients with PAN (Cohen et al., 1980). In most of the cases, the disease is treated with glucocorticoids and cyclosphosphamide (conventional treatment). However, rituximab is the first FDA-approved drug (on April 19, 2011) for any form of vasculitis. There is no known cause or cure for vasculitis. Rituximab works by affecting the action of and eliminating B cells, which are cells of the immune system that have a number of actions. It was initially developed for treatment of a type of lymphoma, and since has been found to be effective for autoimmune diseases, including rheumatoid arthritis and now ANCA-associated vasculitis (Cohen Tervaert, 2011). Refractory patients are exposed to many complications, notably accelerated atherosclerosis. The etiologies of systemic vasculitis are yet unknown. However, dysregulation and/or enhanced expression of pro-inflammatory substances may be involved in the pathogenesis of these diseases. Tumor necrosis factor (TNF)-alpha is a pro-inflammatory cytokine produced primarily by cells of the macrophage-monocyte lineage. The biologic effects of TNF-alpha include adhesion molecule expression, synthesis of proinflammatory cytokines and chemokines, activation of immune system cells (T-cells, B-cells, and macrophages), and inhibition of regulatory T-cells; thus, it may directly participate in vascular inflammation as well as in endothelial cell death via apoptosis (Bansal and Houghton, 2010; Jarrot and Kaplanski, 2014). In addition, TNF-alpha may play a role in neutrophil “priming” inducing membrane expression of proteinase-3 or myeloperoxidase, which are subsequently recognized by ANCA (anti-neutrophil cytoplasmic antibodies) in ANCA-associated vasculitis (AAV) (Radford et al., 1999). Also, elevated levels of plasma TNF-alpha have been shown to correlate with active glomerulonephritis (a variant of vasculitis) and elevated in vitro TNF stimulated peripheral blood mononuclear cells and CD4+ T cells (Ludviksson et al., 1998). Etanercept is a fusion protein composed of 2 extracellular p75 TNF receptor domains linked by the Fc portion of human IgG1. It binds to and neutralizes biologically active TNF-alpha. It has been approved by the FDA for the treatment of rheumatoid arthritis, polyarticular juvenile idiopathic arthritis in patients aged 2 years or older, psoriatic arthritis, ankylosing spondylitis and plaque psoriasis according to the results of randomized phase III studies. The most common side-effects of etanercept are reactions at the injection site (usually redness and sometimes itching), a blocked or runny nose, nausea, mild fever, headaches, dizziness, a rash, and stomach symptoms. More serious and infrequent adverse events are heart failure, infections and skin cancers. In this report we show a case of successful treatment of refractory PAN with etanercept. A 10-year-old patient, with no remarkable medical history, affected by systemic vasculitis was treated with first-line glucocorticoids for 2 years. At relapse, he was treated with intravenous cyclophosphamide (IVCY). After three IVCY pulses, the patient's condition deteriorated with subacute polyarthritis, myalgias and livedo. Furthermore, multiple malacic lesions were observed at brain MRI (Magnetic Resonance Imaging) and signs of sensory-motor polyneuropathy were documented on electromyograms of the legs. Histological examination of neuromuscular biopsy found a vasculitis with fibrinoid necrosis confirming the diagnosis of PAN. Thus, he was initially treated with 60 mg/day of prednisolone, followed by 1000 mg/day of IVCY therapy according to the European League Against Rheumatism (EULAR) recommendations for the management of small and medium vessel vasculitis (European Vasculitis Study Group, 2009). However, he presented resistance to high dose corticosteroid and IVCY therapy, thus he was treated with high dose intravenous immunoglobulin (IVIg) therapy that, according to the literature, can show efficacy in such cases with a good safety profile (Sroa et al., 2010). After 2 months of IVIg treatment (0.4 g/kg body weight/day for 5 consecutive days every month), a partial regression of the disease was achieved. Clinical progression was observed after 6 months. Thereafter, the patient was treated with oral thalidomide (initial dosage 100 mg/day) obtaining a rapid control of signs and symptoms. The treatment was continued for 6 months with a lower daily dose (50 mg/day) until the occurrence of a severe peripheral neuropathy. Considering (i) patient age, (ii) clinical conditions, (iii) disease progression, (iv) previous treatments, and (v) scientific literature reporting involvement of TNF pathway and response to anti-TNF agents in systemic vasculitis, off-label use of etanercept (Bartolucci et al., 2002; Sonomoto et al., 2008) was proposed (25 mg subcutaneously twice a week). Interestingly, after starting the treatment, symptoms and lesions improved without adverse effects. A clinical response was registered after 2 months, with marked improvement in arthralgia, resolution of ulcerations and erythema nodosum and reduction of fatigue. He shows persistent clinical remission after 2 years of treatment. At present, the dosage has been adjusted according to age and weight and he is on treatment with etanercept 50 mg subcutaneously once a week. Our report, as few cases in literature (Feinstein and Arroyo, 2005; Brik et al., 2007; Guillevin and Pagnoux, 2007; Braun-Moscovici et al., 2008; Eleftheriou et al., 2009; Valor et al., 2013; Zoshima et al., 2013), supports a role of anti-TNF therapy in rare systemic vasculitis and, indirectly, it gives evidence that increased levels of TNF-alpha may play a critical role in the inflammatory process associated with PAN. Preliminary data suggest that other several forms of vasculitis appear responsive to TNF antagonists (Behcet's disease, Churg-Strauss vasculitis and giant cell arteritis). Despite aggressive medical management, 22.4% of patients affected by PAN die within 5 years, and of the survivors, medication-induced morbidity is frequent. Thus, there is great need of basic studies on the pathogenic mechanisms underlying these disorders as well as of treatments with high safety and efficacy. Treatment with etanercept could be considered when standard therapies are unsuccessful or contra-indicated.

Impact of nighttime donepezil administration on sleep in the older adult population: A retrospective study

Abstract: Introduction. Although not definite, studies are finding Alzheimer's disease may be related to loss of cholinergic innervation. In order to impact this loss of function, therapeutic agents have been developed to reduce the breakdown of acetylcholine, a neurotransmitter vital in cognitive processes. Donepezil has been used in Alzheimer's disease for improving cognition. Although the package insert suggests nighttime administration to reduce the instance of daytime side effects, some patients report sleep disturbances. Methods. Patient charts at the Tallahassee Memorial Healthcare Neuroscience Center (TMH-NSC) were reviewed. Charts of those patients who met the inclusion criteria were used to determine the correlation between night time administration of donepezil and sleep disturbances. Results. A total of 186 patient charts were analyzed. Of those 186, 103 of the patients were taking donepezil as directed in the package labeling, at night time. Nearly half (47.6%) of the patients taking donepezil at night...

A survey assessing knowledge and perception of prescribers towards generic medicines in Hospital Seberang Jaya

Abstract: Promoting the use of generic medicine has provided an opportunity for policy makers to make effective use of medicines. The current study aims to explore the prescribers’ knowledge, perceptions and willingness to prescribe generic medicines in Hospital Seberang Jaya Penang State, Malaysia. A cross-sectional survey was conducted using a 23-item questionnaire among physicians practicing at Hospital Seberang Jaya, Malaysia. Data were analyzed using Statistical Package for Social Science (SPSS®) version 16. The majority of the respondents 121 (68.4%) were from the age group less than 30 years. Overall, only 7 (4.0%) were aware of the correct National Pharmaceutical Control Bureau’s bioequivalence range that was 80–125%. About 81 (45.8%) of the respondents were unaware of the safety of the generic medicines. Nearly one-third, 57 (32.2%), of the respondents had doubts about the efficacy of generic medicines. Most of the prescribers, 159 (89.8%), insisted on the need for the availability of guidelines or a proto...

The administration of psychotropic PRN medication in Scottish psychiatric intensive care units

Abstract: Information concerning the administration of psychotropic PRN medication in Scottish PICUs is scarce. The medical notes and prescription charts of all patients (n = 75) admitted during the study period were consulted to determine the frequency and nature of PRN practice. 65% of patients (n = 49) were administered up to 11 drugs comprising of antipsychotics (n = 8), benzodiazepines (n = 2) and zopiclone. The most frequently administered PRN medicines were lorazepam, haloperidol and zuclopenthixol. The mean dose administered for oral and intramuscular (IM) forms of both lorazepam and haloperidol were very similar. The mean number of PRN administrations per patient per day was 0.4. 40% of psychotropic PRN administrations were initiated by the nurse with the majority of doses administered at bedtime. Ten patients received an IM injection. Four patients were restrained during these administrations. Documentation pertaining to the rationale for IM administrations and of pre and post rapid tranquillisation physical health monitoring was lacking. This study highlights variation in practice between units, inadequate monitoring and documentation, a possible lack of understanding by prescribers of the differences in bioavailability between oral and injectable forms of medication and relatively limited use of newer drugs.